Changes have been made to the way staff at mental health wards in Surrey deal with emergencies following the death of a 26-year-old Oxford graduate while in the care of a Guildford hospital.

A jury inquest opened into the death of Sarah Shepherd, from Godalming, on Monday November 4.

Sarah died at the Royal Surrey County Hospital on September 13 2011 after being found the previous day in her room in the Noel Lavin unit at Farnham Road Hospital. The unit is now closed.

She was known by staff to have suicidal thoughts and a history of self harm, and the month before she died Sarah left two messages described in the inquest as ‘suicide’ notes, and was found sitting fully clothed in the bath.

Following that incident she was placed on ‘arms-length’ supervision until the following day but by the time she died, her care involved her being checked on at 20-minute intervals during the day and 15-minute intervals at night.

In the days leading up to her death, her main consultant psychiatrist had set in motion a request to the Epsom PICU for Sarah to be referred as her behaviour had led to growing concerns.

Lawyers have been appointed on behalf of Sarah’s parents, Stephen and Margot Shepherd, and the Surrey and Borders Partnership NHS Foundation Trust.

The trust is responsible for both Farnham Road Hospital and the PICU, called the Fenby Ward, at Epsom.

Its associate director of working-age adults in Surrey, Helen Wood, appeared at the inquest on Wednesday to discuss a report she prepared following Sarah’s death.

Assistant Deputy coroner, Alison Hewitt, quizzed Ms Wood on the contents of her report and said: “Looking at the question of actions being taken, a decision was made on September 7 that it would be appropriate for Sarah to be referred but that the paperwork necessary for that was not activated until September 9 and September 10. That timescale, was that in accordance with your policy?”

Ms Wood said: “I would expect that once a decision is made to make a referral, the process would begin almost immediately, and if there was some very good reason why not that this would have been progressed on September 8.”

Mrs Hewitt also explored the issue that there had been no named nurse or other member of staff to take Sarah’s referral forward.

A separate report, written after the death, made recommendations including that a member of staff should be designated to take a patient’s referral forward to avoid confusion.

At the time of Sarah’s death, the emergency response training given to staff on the ward comprised a three-hour course, along with an aid memoir, which, it was suggested, were insufficiently clear about what respondents needed to do in relation to a patient’s breathing.

Ms Wood said training for dealing with inpatients has been increased to day-long sessions.

In relation to the materials used to teach about breathing and how to use CPR, Ms Wood said: “I think based on what has been heard at this hearing, the trust will be very keen to revisit that part of the training.”

Other changes made since Sarah’s death include bin liners and bin bags being banned on certain wards, and the introduction of a daily risk record for each patient.

Ms Wood said the Noel Lavin unit was due to close for redevelopment in March last year but that redevelopment of the hospital was delayed.

The trust proceeded to shut the unit in any case, in part due to Sarah’s ‘untimely death’.

Building work finally began last month and a new PICU unit is planned for Farnham Road Hospital as a replacement to the unit at Epsom.